Musings on Economics, Finance, and Life

A Note on End-of-Life Health Care

It’s often said that end-of-life care makes up a disproportionate share of overall health care spending. For one very thoughtful discussion, see this article in Daily Finance.

Such claims strike me as plausible as an after-the-fact accounting matter. But I’ve always wondered how often patients and their caregivers know that they are providing end-of-life care? And how often do they have hopes – perhaps even expectations – that the patient will recover, but the treatments don’t succeed?

The recent passing of my father-in-law illustrates this question. He died early this morning after almost two weeks in intensive care fighting pneumonia and trying to recover from a recent stroke.

Until yesterday, the plan was simple: provide fairly aggressive treatment in the ICU to defeat the pneumonia so that he could return home. It would take time to assess damage from the stroke, but at least he would be able to get care at home from his extended family.

That plan collapsed yesterday as the pneumonia worsened, his kidneys failed, and he had a final stroke.

The record books will thus record about 10 days of ICU care for him in his final 10 days of life. From the perspective of Esther and her family, though, it really felt like 9 days of ICU care with the hope of improving and extending his life, and 1 day of ICU care knowing that the end was imminent.

Although my father-in-law likely didn’t benefit from that last day of ICU care, it’s also worth noting that some of his family members did, because they had an opportunity to come say their good byes in person (even if he couldn’t hear them).

All of which is to say that his end-of-life care provided some benefits – some probability of recovery plus some solace for family members – even as it ultimately failed at substantial cost. Spending on end-of-life care is a natural place to look for potential cost reductions as we try to “bend the curve” on health spending. The challenging part, however, will be balancing potential savings against the potential benefits of such care.

(For completeness, I should note that in our case, the balancing of these costs and benefits was entirely a private matter because Esther’s father had no private insurance and was not eligible for Medicare because he had moved back to Mexico. Similar episodes play out thousands of times every day, however, for people covered by private and/or public health insurance.)

This issue could be the 800 pound gorilla in the room of health care policy. But it can’t be resolved as a matter of health care policy until we resolve it as a culture, exploring fully the moral and ethical dimensions. It is a tough topic and we must take it on, but what is the broad venue? What’s the driver to force a national discussion?

Economists and health policy experts talk about costs, and in a world of scarce resources, costs matter. But the discussion is about even greater issues. When these are resolved, I suspect some of the cost issues will be resolved, as well.

Thanks everyone for your kind thoughts. Esther and I appreciate them. Judging by the comments here and the emails I’ve received, many folks have had similar experiences with “end-of-life” care being “end-of-life” only in hindsight or, as Brooks describes more precisely in his link, only “end-of-life” probabilistically.